心脏瓣膜置换术后行外科手术的临床观察

Clinical observations on patients with surgical treatment after heart valve prosthesis implantation

目的探讨心脏瓣膜置换术后患者行外科手术的安全性。方法回顾分析1996年1月至2005年12月收治12例心脏瓣膜置换术后因外科疾病行外科手术的临床资料,12例患者均口服华法林进行抗凝治疗。心功能Ⅰ～Ⅲ级。7例择期手术,5例急诊手术。择期手术者停用华法林2～3 d,急诊手术者术前6～8 h 肌内注射维生素 K_15～10 mg,术前凝血酶原时间(PT)平均值分别为15.1和15.3 s,凝m酶原国际标准化比值(INR)分别为1.24和1.30。术中视创面渗血情况,予维生素 K_15～10 mg 静脉滴注。结果 12例患者手术时间20～160 min,手术出血量5～280 ml,未发生术中术后大出血、血栓、心力衰竭等并发症。结论心脏瓣膜置换术后的患者应用维生素 K_1并将 PT、INR 控制在15 s、1.30左右,结合术中细致操作,加强围手术期管理,进行外科手术是安全的。

Objective To evaluate the safety of surgical procedures for patients after heart valve prosthesis implantation. Methods Clinical data of 12 cases with heart valve prosthesis implantation undergone other surgical treatment from November 1996 to December 2005 were retrospectively analyzed. All the cases had routine oral warfarin with prothrombin time （PT） of 20. 0-28. 3 s averaged 23.5 s, international normalized ratio （INR） for prothrombin of 1.79-2. 23 averaged 1.95 and heart functional classⅠ-Ⅲ Among them, appendectomy was performed in three cases with acute appendicitis, reposition and repair in one with inguinal hernia, radical gastrectomy in two with gastric carcinoma, left hemicolectomy in one, cholecystectomy in three, left femoral head replacement in one, and bilateral high ligation and ablation of great saphenous vein in one. Elective surgical operation was performed in seven cases, and emergency operation in five. In those with elective surgery, warfarin was stopped 2-3 days before operation, while 5-10 mg vitamin K1 was injected intramuscularly 6-8 hours before emergency surgery with preoperative median PT of 15.1 and 15.3 s and median INR of 1.24 and 1.30, respectively. In operation, 5-10 mg vitamin K1 were injected intravenously into the patients by drip depending on their bleeding on the surface of wound. ECG, blood pressure, hemoglobin and oxygen saturation were routinely monitored for all the cases intraoperatively and postoperatively. For the cases with heart function above class Ⅱ, fluid infusion was adjusted based on intubated central venous pressure, and for those with general anesthesia, analyses of blood gases and electrolyte were monitored routinely in operation. Results Operation time averaged 20-160 min in all the 12 patients, with blood loss 5-280 ml in average and without complications of massive hemorrhage, thrombosis and heart failure. Conclusions Surgical operation was safe for patients with heart valve prosthesis implantation, if preoperative PT and INR were adjusted to about 15 s and 1.30, respectively by cessation of warfarin or application of vitamin K1 , combined with careful manipulation and strengthened perioperative management.